Wellness Quiz

Problems falling or staying asleep
Not true Somewhat true Very true

Energy highs and lows throughout the day
Not true Somewhat true Very true

Feel tired all the time
Not true Somewhat true Very true

Need caffeine (coffee, tea, cola) to get going in the morning
Not true Somewhat true Very true

Get less than 8 hours of sleep per night
Not true Somewhat true Very true

Easily fatigued
Not true Somewhat true Very true

Decreased ability to handle stress
Not true Somewhat true Very true

Tendency to overwork with little time for play or relaxation
Not true Somewhat true Very true

Crave sweets
Not true Somewhat true Very true

Reduced sex drive
Not true Somewhat true Very true

Dry hair, skin, nails
Not true Somewhat true Very true

Mood swings, irritability
Not true Somewhat true Very true

Breast tenderness/swelling, cramping, bloating around period
Not true Somewhat true Very true

History of birth control use
No Yes

Polycystic ovarian disease
No Yes

Acne
Not true Somewhat true Very true

Irregular menstrual cycles
Not true Somewhat true Very true

Hot flashes or night sweats
Not true Somewhat true Very true

Are you 45 years of age or older?
No Yes

Recent weight gain or history of low calorie dieting
No Yes

Regain weight after dieting
Not true Somewhat true Very true

Skip meals
Not true Somewhat true Very true

Eat low fat foods
Not true Somewhat true Very true

Frequently think about weight issues
Not true Somewhat true Very true

Tendency to overeat sweets, bread, carbs
Not true Somewhat true Very true

Compulsive overeating, history of eating disorders
Not true Somewhat true Very true

Family history of diabetes or hypoglycemia
No Yes

Feel shaky if hungry, or lightheaded if skip meals
Not true Somewhat true Very true

Constipation or diarrhea
Not true Somewhat true Very true

Frequent antibiotic use in the past
No Yes

Stool is unusual shape, color, or consistency
Not true Somewhat true Very true

Food allergies/sensitivities, or “love” specific foods
Not true Somewhat true Very true

Difficulty digesting dairy products/lactose intolerance
Not true Somewhat true Very true

Abdominal pain or cramping
Not true Somewhat true Very true

Abdominal bloating or distention, gas
Not true Somewhat true Very true

Feel worse after eating
Not true Somewhat true Very true

Heartburn/indigestion
Not true Somewhat true Very true

Anxiety, panic attacks, excess worry
Not true Somewhat true Very true

Migraine or tension headaches
Not true Somewhat true Very true

Sadness, depression, lack of motivation
Not true Somewhat true Very true

Overeating sweets, especially in the evenings
Not true Somewhat true Very true

Emotionally sensitive/cry easily
Not true Somewhat true Very true

Concentration and focus problems
Not true Somewhat true Very true

Eat as a reward for pleasure, comfort, numbness
Not true Somewhat true Very true

History of use of anti-depressant medications
No Yes

Chronic pain or chronic fatigue
Not true Somewhat true Very true

Allergies
Not true Somewhat true Very true

Recurrent colds and/or infections
Not true Somewhat true Very true

Significant work-related stress
Not true Somewhat true Very true

Outstanding personal achievement within last year
No Yes

Change in financial status within last year
No Yes

Change in family member’s health within last year
No Yes

Personal injury or serious illness
No Yes

Divorce or end of relationship
No Yes

Death of loved one
No Yes